A Qualitative Examination of the Role of Small, Rural Worksites in Obesity Prevention

Introduction The prevalence of overweight and obesity in the United States is highest in rural counties. We explored social support, policies, and programmatic resources that encourage more healthful diets and participation in physical activity among employees of small, rural worksites. Methods We conducted in-depth interviews with 33 employed adults aged 50 years or older in rural Georgia about access to healthful foods and opportunities for physical activity at work; conversations about exercise, weight loss, and eating healthfully in general; and worksite nutrition and physical activity programs; and we asked for suggestions for making the worksite more healthful. The research team developed a codebook, and 2 coders coded each transcript. Data were analyzed and reports were generated for thematic analyses. Results Participants from rural worksites, most with fewer than 50 employees, cited lack of vending machines and cafeterias, health promotion programs to address healthful eating and exercise, and facilities for physical activity as barriers to eating healthfully and engaging in physical activity at work. Many participants reported conversations with coworkers about how to eat more healthfully by making more nutritious choices or preparing food more healthfully. Participants also discussed the importance of engaging in physical activity on their own and gave suggestions on ways to incorporate exercise into their routines. Participants' access to healthful foods at work varied, but barriers such as being too busy, worksite location, and no worksite cafeteria were noted. Some workers reported engaging in physical activity at work, and others reported a heavy workload and lack of time as barriers. Conclusion Building on the social environment and implementing policies for healthful eating and participation in physical activity may help address obesity prevention in rural workplaces.


Introduction
Worksites are practical settings for health promotion, and worksite health promotion can improve employee productivity and health, including playing a role in modest weight loss (7)(8)(9). Although results are mixed, worksite intervention studies aimed to improve dietary and physical activity habits of employees are promising when combined with strategies that also target social and organizational support, environmental change, and policy change (10)(11)(12)(13).
However, despite the promise of worksite environments in supporting employees' healthful eating and participation in physical activity, small or rural businesses typically have fewer health promotion programs than larger employers (8,(14)(15)(16). A recent national survey of worksites indicated that worksites with more than 750 employees consistently offered more health promotion programs than did smaller worksites (17). Small worksites face barriers such as lack of financial resources and infrastructure to conduct health promotion programs (8,14). Because more than 50% of workers are employed by businesses that have fewer than 100 employees, learning more about small and rural worksites and their potential for providing health-promoting environments and programs is important (14,16,17).
The purpose of this qualitative study was to learn more about the available intervention strategies and policy and social supports of worksites in rural areas. We examined the social support, policy, and programmatic resources in rural worksites that may encourage more healthful diets and participation in physical activity among their employees.

Methods
The Emory Prevention Research Center (EPRC), its Community Advisory Board (CAB) of representatives from multiple community sectors, and the Southwest Georgia Cancer Coalition partnered to conduct this research. The CAB assisted with decisions about study design, the data collection instrument, and interpreting results. A Southwest Georgia Cancer Coalition staff member supervised data collection and the local residents trained in interviewing techniques by Emory faculty and staff who conducted the interviews. The Emory University institutional review board approved the research protocol.

Sample and procedures
The study was conducted during May through September 2005. Eligibility requirements were being African American or white, aged 50 years or older, currently living with at least 1 other person, and residing in the Georgia counties of Calhoun or Terrell for at least 10 years. Calhoun (population 6,094) and Terrell (population 10,657) counties are located in rural, southwest Georgia and are characterized by high rates of poverty and low educational attainment (18). We employed a snowball sampling approach to recruit 60 participants, divided evenly by sex and race. The CAB decided to focus on adults aged 50 or older because members thought that prevention of cancer and other chronic diseases would be more salient for adults in this age range.
Interviewers recruited participants through snowball sampling, starting with personal contacts, local businesses, and organizations. They were also recruited by going door-to-door in neighborhoods and at civic associations and by using advertisements in local papers. Interviewers screened potential participants in person to ascertain eligibility, inquiring about age, living with another person, and time lived in Calhoun or Terrell counties. Sixty participants were interviewed in their homes or public areas, and all provided written informed consent. All interviewers attended a 1.5-day training about the project and qualitative interviewing methods. They completed several pilot interviews and received feedback on their technique. The trained local residents conducted the interviews using a semistructured interview guide; they were race-and sexmatched to respondents.

Instrument
The full interview guide explored how social and physical environments in the home, work, and church influence healthful eating, participation in physical activity, and tobacco use. Only themes regarding how the worksite affects healthful eating and participation in physical activity are reported here. Data on the role of the home and neighborhood environments on these behaviors have been published elsewhere (19).
Questions about worksite environments that promoted healthful eating and weight loss asked about the availability of a cafeteria and vending machines, discussions with coworkers about eating healthfully and losing weight, and availability of worksite programs to help people eat healthfully or lose weight (Appendix). Questions about physical activity environments and opportunities asked about participating in physical activity at work, conversations with coworkers about participating in physical The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
activity, and the availability of worksite programs or facilities for participating in physical activity. We also asked participants to offer suggestions on how to improve their worksites. The interviews typically took 60 minutes to complete. Interviewers gave participants a $20 gift card from Walmart as compensation for their time.

Data analysis
The interviews were transcribed verbatim. We excluded 2 interviews in the final analysis because of tape-recording problems. The research team developed a codebook to cover major themes for each topic covered in the interview discussions. Two coders then coded each transcript independently and resolved discrepancies through consensus. QSR-N6 software (QSR International, Cambridge, Massachusetts) was used for data storage, retrieval, and analysis. The coders generated N6 reports with all comments associated with particular codes. Content analysis was performed to identify the range of responses and major themes (20). To identify patterns and themes by sex and race, matrices were constructed (21,22). For example, staff generated a report to retrieve all text associated with availability of healthful food choices at work by sex and race. One researcher identified themes and a second confirmed the themes (eg, vending or cafeteria options). The researchers defined strength of a theme by number of responses: 5 or fewer responses being weak, 6 to 14 responses being moderate, 15 responses or more being strong.

Results
Of the 58 respondents, 33 (57%) reported being currently employed outside of the home. Of these 33, most were white men and had a mean age of 59 years (Table 1). Most worksites employed 50 or fewer people; 16 participants reported working with 4 or fewer people. Many participants worked in small retail stores and offices (eg, art shop, florist, bookkeeping), and others worked at factories, in construction or education, or were self-employed (eg, landscaper, computer repairman).

Healthful eating at work
Opportunities for healthful eating at work Cafeterias and vending machines. Two strong themes that emerged were the lack of cafeterias and vending machines in these rural worksites. Approximately half of respondents reported that cafeterias were not present at their worksites. Those participants whose worksites had cafeterias described prepared meals, meats and fish, sandwiches, side items, and desserts as being generally available: When we had the meal, I had the vegetables and all, but then they quit cooking anything but the chicken and chicken tenders and so I wound up eating chicken tenders. I would make me a chicken tender sandwich, and that was fried and it was not good for me. (white female participant) A little more than half of respondents reported that vending machines were not present at their worksites. Of participants whose worksites had vending machines, only 2 stated that they purchased food daily from a vending machine. Vending machines typically offered food such as snacks (eg, candy, chips), beverages, and occasionally salads and sandwiches: A few respondents mentioned reasons for bringing food to work, which included not being able to leave work during the day to get food, the convenience of bringing food or snacks with them to work, and concern for the nutritional quality of the foods they eat: It usually has to do with tight schedules. Like, when we're shipping something and I just can't leave because I don't know when the truck's going to pull up. (white male participant) A couple of respondents mentioned that refrigerators or microwaves were available for them to store and prepare food at their worksite: We do have a refrigerator that soft drinks and water are kept in, but other than that.

Conversations with coworkers about healthful eating and weight loss
Two strong themes that surfaced were conversations about eating healthfully and losing weight with colleagues at work (Table 2). Most respondents (n = 17) reported having conversations with coworkers about eating healthfully, with the exception of African American male participants. Moderate themes from the conversations centered on the types of food participants eat (healthful or unhealthful) and methods to eat healthfully. Weaker themes were the methods participants use to prepare foods and discouraging coworkers from eating unhealthful foods.
Many conversations about losing weight at the worksite involved 1 coworker offering advice to other coworkers on how to lose weight, with exercise mentioned most often as a moderate theme. Participants also discussed conversations about eating healthfully to lose weight. Strategies mentioned were using weight-loss programs (eg, Weight Watchers), eating prepackaged meals (eg, Lean Cuisine, Healthy Choice) and eating home-cooked meals for lunch.

Barriers to healthful eating at work
More than half of respondents identified barriers to healthful eating at their worksite. One moderate theme that emerged was the lack of time. Other barriers that emerged as weak themes were the presence of "tempting" foods, limited selection of healthful food options at worksites, job stress leading to eating unhealthful foods, and location of worksites, which could limit access to healthful foods.
Participants who reported no barriers to eating healthfully at work had flexible schedules, which allowed them more choices to eat healthful lunches, and others felt it was easy to bring in healthful lunches or snacks to eat throughout the day: Another strong theme was the lack of health programs. None of the respondents stated that there were currently programs at their worksites to facilitate healthful eating or weight loss. A few participants described programs that had been implemented in their worksites in previous years and commented that these programs had been unsuccessful.

Suggestions for how worksites could encourage healthful eating
Most respondents had suggestions for what worksites could do to encourage more healthful eating among employees. Suggestions that emerged as weak themes included providing more healthful food options, offering fresh fruits The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. and vegetables, using insurance premiums as incentives, providing educational materials, and having a designated lunch break for all employees. A few participants reported that worksites could not do much to encourage healthful eating because of the small size of the work facility; the varying location of the worksite, which may be miles away from restaurants or stores; and the belief that eating healthfully is a personal responsibility and not something that should be determined or influenced by the worksite. The few respondents who said they were not physically active at work explained that their job was sedentary in nature (ie, involved sitting at a desk for most of the day).

Physical activity at work
A few respondents noted that physical activity should be completed during personal time outside of the workplace.

Conversations with coworkers about physical activity
Approximately half of the respondents described having conversations with coworkers about physical activity. Common topics included sharing their own exercise practices (moderate theme) and encouraging one another to exercise (weak theme). A few respondents talked about how age had affected their physical activity level (Table  3).

Facilities and programs to encourage participation in physical activity at work
Almost all of the respondents reported no exercise facilities were provided at work, a strong theme. Two of the 3 exceptions were teachers who mentioned having access to a gym and a track. None of the respondents reported having exercise programs at their worksites, though a few informal activities existed. Two respondents reported that coworkers organized walking groups with other coworkers at the worksite. A few respondents reported that employees take breaks during the work day to walk outside.

Barriers to physical activity at the worksite
Slightly more than half of the respondents felt there were barriers to being physically active at work. Moderate themes were the sedentary nature of the job or a schedule that does not permit exercise during the work day, because of heavy workload or irregular hours. Limited space for exercise was also mentioned as a barrier.

Suggestions for how worksites could encourage participation in physical activity
When asked, almost half of the respondents had no suggestions for what their worksite could do to help employees be more physically active. Of those who had suggestions, a few said that allotting time to employees to exercise during the workday would be encouraging, and others suggested that employers provide exercise equipment or designate an area for employee exercise. A few others said that it was not necessary because their jobs were already physically demanding.

Discussion
This study was a qualitative examination of programs and social support for physical activity and healthy eating in rural, and primarily small, worksites. Other studies of worksite health promotion have been quantitative and have focused on large businesses (23,24). Findings from this study were unique. Specifically, our results indicate that small, rural worksites tend not to have vending machines and cafeterias, have more collegial support The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
for healthful behaviors, and have almost no established health promotion programs.
Strong themes that emerged were respondents having conversations with coworkers about eating healthfully, losing weight, and engaging in physical activity. Small worksites may provide a greater sense of community and may offer a supportive social environment for behavior change through colleagues or groups (14,16). Similarly, Tessaro and colleagues found that women in rural worksites believed that social support in the workplace could facilitate behavior change for healthful living (25). We also found that, as previously reported, some employees in these settings are already physically active on the job; therefore, health promotion in these types of worksites could focus on leisure-time physical activity or other health issues (26). Social support may be important for promoting health behaviors in smaller worksites by changing social norms and company culture for healthful lifestyles and by offering models and supports for behavior change (8,27).
The strong theme of limited or no cafeteria options or vending machines in rural worksites is in contrast to larger worksites. A major barrier to healthful eating was limited selection of healthful options and greater presence of unhealthful foods. Some comments focused on the unhealthfulness of Southern-prepared meals such as fried foods and sugary desserts. Expanding healthful food options or increasing their visibility and offering healthful options in vending machines can influence healthful eating in larger worksites (11). However, other methods such as offering an opportunity to buy locally grown produce at work (28) or educating employees about healthful eating at home, since many participants in our study reported going home for lunch, may work better for rural businesses. Furthermore, respondents were interested in education, reminders, and incentives to encourage employees to eat more healthfully. These educational and policy actions taken by employers can promote a more healthful worksite (14).
Lack of facilities for physical activity at these rural worksites was a strong theme, which is consistent with previous research (16,29). Other reported barriers to engaging in physical activity at work, which emerged as moderate themes, were limited space, schedules, and heavy workloads. Suggestions were made for provision of equipment or allotment of time for physical activity at the worksite. Worksites can provide opportunities for exercise through policies of flexible schedules and breaks, strategies that promote physical activity (12). Worksites can offer enhanced opportunities for physical activity by changing the local environment through creating walking routes, providing exercise equipment, or providing access to existing nearby facilities (30). Easier solutions for small worksites may include creating walking routes around facilities such as parking lots or arranging for services at nearby fitness facilities.
Similar to previous studies in small businesses (16,24), respondents reported that their businesses offered few to no health promotion programs for nutrition or physical activity. Several strategies to reduce this barrier are for businesses to pool costs or programs, refer employees to community sources for services, and provide information from government and professional groups, which are available for no or low cost (16). Additional resources for wellness programs in rural areas are community organizations, community centers, schools, or churches.
Our study has several limitations. The sample of respondents may not be representative of workers in other rural areas. We did not validate respondents' reports of the presence of worksite cafeterias, vending machines, and program offerings by conducting on-site visits. Respondents who reported being active at work may not meet the amount and type of activity recommended by national guidelines. Furthermore, we asked respondents to answer questions about their workplace offerings to glean insight into rural worksites; the reported availability of healthful foods, programs, and facilities varied on the basis of worksite setting.
Given the fact that more than 55% of Americans work for employers with fewer than 100 employees (15), access to worksite health promotion is critical. Future research could systematically assess the differences in policies that are health promoting at worksites of varied sizes and the effectiveness of social support programs, policies, and environmental changes on healthful eating and participation in physical activity at rural worksites.

Acknowledgments
This publication was supported by cooperative agreement no. U48 DP 000043 from the Centers for Disease Control and Prevention.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.  The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.